Dr. Timothy Murray, MD, MBA is the founder of Ocular Oncology and Retina in Miami, which he started in 2012 after a 21-year stint at the Bascom Palmer Eye Institute. He has published over 300 chapters and articles, and serves as an active editor and peer reviewer for multiple publications in ophthalmology and the specialized fields of ocular oncology and vitreoretinal surgery, as well as an Associate Examiner for the American Board of Ophthalmology. He is a Fellow of ARVO and ABO, a member of the Macula Society and Club Jules Gonin, a past Executive Committee Member of the Retina Society, and the current President of ASRS.
We sat down with Dr. Murray to talk about practice ownership, what brought him to pursue an MBA as an ophthalmologist, and his advice for ophthalmologists starting out in the field.
Note: This interview has been edited for length and clarity.
Reading about your career, one of the (many) things that stands out is how in 2005, while you were already established as a physician, you decided to pursue the MBA degree. A few years later you left Bascom Palmer to open your own practice—but what led you to pursue this other degree in the first place?
I started at Bascom Palmer in 1991, and that was the place that I wanted to go more than anything.
I was the last person that Ed Norton, the chief and chairman at Bascom Palmer, hired before he stepped down as chairman. I found that over time, it was getting harder and harder for me to be able to take care of my patients in the way that I wanted.
Most of us in retina have very large clinics now, and the only way that a large clinic can allow you to take good care of your patients is if there are significant efficiencies in the clinic. In a retina clinic, the techs do the anterior segment exam: they measure your pressure, dilate your eyes, and then while your eyes are dilating, typically you'll get your photographs and OCT. And because I have a tumor specialty, my patients also get ultrasound. Towards the end of my time at Bascom Palmer, the visits for those exams and treatments were taking almost five hours.
Many retina patients—particularly oncology patients—aren’t young anymore, and five hours at a medical office is a lot. But I think that this concept is actually how you want to provide care: you want to be able to offer your patients the ability to see them, evaluate them, and treat them all in one sitting. That’s rare in medicine—typically you have to go to different labs to get blood work or chest X-rays, and then you have to come back to your doctor who interprets all of that before they can tell you what they want to do.
As ophthalmologists, I think that we can be point of care specialists—if you see me, you want your diagnosis, your testing, and your treatment plan, and you can watch your treatment get started all at the same visit.
I realized that the reason visits were taking so long was a system-wide problem. It wasn't that these exams required that amount of time, because on days when Bascom Palmer was less busy or better staffed or more efficient, my patients could get in and out in two hours. At the time I was involved with our surgical committee, and I was actively advocating for better efficiencies within the administrative circles of the department. But I kept hitting this wall, where the feeling was, “You’re the doctor, you don’t know anything about administration.”
At that time, my chairman, who is a well known retina specialist, had his MBA from Wharton. So I thought, well, maybe this is an opportunity. The University of Miami had an executive MBA program that was critically focused on healthcare, and I was lucky enough to be selected for the 2-year program.
When you’re in an MBA, there’s a lot of projects outside of classwork. In my MBA program, you got to pick how you did every project. Because I was focusing on how I would make my practice at Bascom Palmer better for my patients, every project I did was something related to the University of Miami and Bascom Palmer.
I got three main things out of the MBA: first, I really got a significantly better understanding of the language of business. I got a significantly better understanding of operations management, but the best part for me, and something I’ve always been interested in, was leadership development.
The MBA allowed me to go and meet with our administration and present my ideas for improving our practice efficiency from a business perspective. Instead of saying we would be doing this for the patients—which hadn’t worked—I changed the language to present the business benefits. And suddenly, we were able to make these changes.
So the MBA was a way to develop your own understanding of the way your position fit in with the administration, how the department and the clinic functioned, but also gave you the tools you needed to affect the change you wanted.
You were working with people who weren't necessarily on the same page when you were speaking the language of patient care, but when it came to speaking the language of business efficiency, that code switching was absolutely invaluable.
In my first week in the MBA program, they asked us to rank our priorities in our approach to healthcare. In our class, there was one other MD, and we had a couple of CEOs from healthcare divisions, a few people who were directors, and a broad array of people from insurance and other aspects of healthcare and academia.
Only the other MD and I ranked our top 10 priorities as all related to patient care. Everyone else there had no patient care priorities on their list at all, and I thought that was so telling—the doctors aren’t focused on the business, because we’re focused on patient care, and the administration isn’t focused on patient care because they’re focused on the business.
When it comes down to communicating, I don't want to say it's an old boys’ club, but you have to be able to understand the audience and you need to speak to them in their language. And when I was able to speak to them from the setting of an MBA and not so much from my MD, people listened to me in a very different way.
It was kind of sad, because I was looking at how people responded to me and thinking, I am asking for the same thing. I didn't ask for anything different. I just used a different approach, and suddenly that made it understandable to the administrative group responsible for the operational management of the hospital. It was huge.
I do think that that ability to understand and have a shared language, to communicate what you want to achieve in a way that people can appreciate within their own context, is a game changer. That's probably one of the best things that the MBA does for a physician.
Would you suggest this course of action to other ophthalmologists? What might be some difficulties for ophthalmologists looking to pursue an MBA?
Now, it took two years of my life, and I did it while I was practicing. That was a huge commitment for a family. Understand that it's not without its hardships, but it was worth it.
In a way, it was actually fun to go back to school to get my MBA, because I didn't have that same focus that I had in the past where I was focused on getting great grades. I was going back to school just for me, which took a lot of the pressure off. I had a whole different focus on how I listened to my professors and what I was looking for.
Now, several of MBA classmates and professors are my patients, and when they come in they’re very impressed to see some of the things they lectured on in operations management play out in a busy retina practice.
And then, when I left Bascom Palmer in 2012, I think that the reason I could leave and establish the practice that I did so quickly was very much attributable to my MBA. I had to get financing. I had to put my business plans together. People wanted to know what the ROI is going to be like, and they wanted alternatives.
I use my MBA much more in private practice because it touched all aspects of the transition for me. So I think whether you are in academics or whether you have a private practice, that if you have the opportunity and the interest in an MBA, you will really grow into your understanding of the business of your practice and the business of medicine.
But it also allows you to better interact with people outside of medicine.
Part of the whole thing about communication and understanding what people’s priorities are is that it comes back to doctor to patient communication as well. Being able to understand the priorities of people who aren’t your patients can also help you understand the priorities of your patients.
I think that's absolutely correct. I think most of us tend not to be judgmental in our patient management, but I think you always bring your own inherent biases when you interact with patients. Sometimes I'll look at something and I'm flabbergasted by the choices that my patients make. But if I step back and I understand a little bit better about, you know, their social circumstance, or their financial circumstances, you get a much better understanding of the choices that they've made.
You can't take care of your patients all the same: they're all unique individuals. You have to understand that, or you won’t be able to speak with them in a way that benefits the medical care that you want to provide.
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To back up a little, you mentioned that everything you were doing while you were in the process of getting that MBA was to bring back to Bascom Palmer, but then in 2012 when you opened your private practice, you said it wouldn't have been so streamlined, it wouldn't have gone as well as it did as quickly as it did.
Aside from the MBA, what kind of resources do you think an ophthalmologist who wants to open or run a private practice should look for? What kinds of steps should an MD take to broaden their horizons and get a better understanding of these aspects of healthcare administration?
Almost everybody leaving med school either joins academic practice or an existing single-specialty or multispecialty group. So people who actually go out and set up a practice on their own are incredibly rare in the world that we're seeing now.
Having said that, it's definitely doable.
However, it takes a different mindset. When you open a private practice, you're putting a lot of your own resources at risk. So when I started my practice, I bought an office, I renovated the office, I bought technology for the office, and then I recruited the staff for the office. And the initial outlay to do all of that is significant.
When you're young, I think it's hard to be comfortable with the level of financial risk that is entailed with private practice. But looking back, I left Bascom Palmer after 20 years, and if I’d known I was going to leave for private practice I would not have left that late in my career. I would have left 10 years earlier.
The great thing about academics is that you can go into academics and in those first five years, you have an opportunity to establish yourself within the community, and you become a much more attractive recruit for a private or group practice. For many people, the move from academics to group or multi-specialty practice after a few years is a natural transition.
I know a few people besides myself who have made the transition to private practice after over a decade in academics, and that’s very different. I think that all of us would tell you that if we actually knew we were going to end up in private practice, we would have transitioned much sooner.
When you start practicing after fellowship, take the time to come to an understanding of what your passion is and where you want your career to go. You’re in a much better position to look at practices differently. There’s never a perfect time to make a change, and you can’t wait for perfection. You just have to make the best decision you can make.
Also, with what's going on with private equity, it's really unclear what the landscape of ophthalmology is going to look like in five years. I think we really don't know, and I think you almost never know. Now the world is changing, and we're seeing a lot more practice consolidation, and we're seeing much less independent practices. It's evolving, and I don't think we all really understand the ramifications of those changes.
The whole question of private equity is playing out in every field across healthcare, both in terms of the effects on patient care, as well as on the long-term careers of physicians, including ophthalmologists. When an ophthalmologist completes their residency or fellowship, what can they expect to see happen in the next five years? Is it worth it to go into private practice, or to structure their career with the hope of ownership, when there's the chance that a private equity firm is going to swoop in and buy out the practice before they've put in their two years or however long it takes to buy into the practice?
In the traditional model of private practice, you would buy into the practice after working there for two or three years, investing in the practice and then eventually becoming a partner in the practice. The benefits of that, of course, is that you share proportionally in the returns to the practice.
The best compensation used to be in practice ownership. For academics, which traditionally paid so much less than private practice, people who transition are often just thrilled to be working in a private practice at all. But now what’s changing is that these specialty groups are selling to private equity, and ownership is no longer an option. When you’re working in a practice owned by private equity, you’re an employee. You start off at a significantly higher base salary, but you never have the opportunity for ownership.
Personally, I’m a big believer in ownership, not because of the compensation, but because I think that when you own something, you're more invested in it. Ownership drives performance for you and your staff.
It’s going to be interesting to see what these equity-owned practices are going to look like five years from now. We’re in a bubble where there has been a rapid acquisition of some very established, nationally recognized practices and we just don't know how that's going to play out.
At the same time, it gives another set of opportunities to those just finishing residency. The first main opportunity is to join a healthcare system, such as Kaiser Permanente or the VA system, where you’re not ever going to buy into those systems. You’ll always be an employee. The second opportunity is to go into an equity-acquired practice, where you’re still an employee, but the compensation rates are quite good. Or third, you can join a traditional practice that isn’t looking to be acquired by private equity, where the opportunity still exists for you to buy into the practice and achieve ownership.
It’s a cliché because it’s true, but building a successful practice is not possible without an incredible staff. What are your tips for evaluating good people when you're hiring? Whether it’s associates, practice staff, or other ophthalmologists, what are the signals that you look for that say to you, this person is going to take my practice to the next level, or help me do that?
Since I do ocular oncology, there are parts of my practice that are really unique, and there isn’t a large pool of qualified support people for many of the things that I do.
Take ultrasound—when I went into private practice, I took several of my key people from Bascom Palmer with me, which is kind of like cheating, because I knew them. In fact, I took the person who I think is the best ultrasound tech in the United States with me!
So the easy answer is, of course, to look for people you’ve had the opportunity to work with.
Of course, the problem is that most of us don’t have the luxury of being able to see the people we’re looking to recruit in a work situation. So the thing that I look for more than anything else is passion and commitment. The person who makes or breaks your day isn’t necessarily the most brilliant—it’s the person who just will not quit until the job is done.
In medicine, that’s the resident or fellow who won’t go home until they’ve checked all of the labs. Most people will say they’ve got the labs, and that’s all they need—and some will say, I’m not done until I see the results. Those are the people I want to work with. I want to work with people who don’t quit, who are always pushing themselves to do better.
Some people come in and they see their work simply as a job, and some people come in and see themselves as part of a team. I want to hire the person who always thinks of themselves as part of a team.
This is the strength of private practice: people want to work for someone. The best people I’ve worked with were never doing their job for Bascom Palmer—they were doing their jobs for themselves and their MDs. In an academic setting, you don’t have the same ability to reward people, because you’re in an institution and there are constraints. But in private practice, you can take care of your people in a different way. We all want to feel valued, and in a private practice environment, you have much more latitude to demonstrate that you value your people in both tangible and intangible ways.
And finally, the other big thing I look for is interpersonal skills. As ophthalmologists, we can see 80 patients a day or more. So everyone in the clinic has to be able to interact comfortably with people who are often not at their best: your patients are anxious, or worried, and they need someone to connect with. The art of healthcare delivery is making sure that patients feel like they’re not just one of a dozen people moving through the clinic, but that they’re being seen and taken care of.